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Then, mental restlessness (Fanzao) occurs; when the pathogenic factor enters the abdomen, fullness in the lower abdomen (Fuman) results from its presence in the lower part. With both pathogens pressing upon and gathering in the chest and abdomen, mental restlessness and abdominal fullness occur. Employing one method of inducing vomiting and one of purging constitutes a simultaneous release of both exterior and interior syndromes.

Formula for Gardenia and Magnolia Bark Decoction (Zhizi Houpo Tang)
Gardeniae Fructus (broken open, 14 pieces), Magnoliae Officinalis Cortex (processed with ginger juice, 4 liang), Immature Bitter Orange (pulp removed, stir-fried, 4 liang).
The above three herbs are boiled in 3.5 sheng of water to obtain 1.5 sheng. The dregs are removed, and the decoction is divided into three doses. Take one dose warm. If vomiting occurs, stop taking subsequent doses.

In cold damage (Shanghan), if a physician uses pill medicines to cause severe purging, and body heat persists with slight mental restlessness, Gardenia and Dried Ginger Decoction (Zhizi Ganjiang Tang) is indicated.
[Commentary] "Gardenia and Dried Ginger Decoction" should be Gardenia and Fermented Soybean Decoction (Zhizi Chi Tang), and "Gardenia and Fermented Soybean Decoction" should be Gardenia and Dried Ginger Decoction. It is inconceivable that dried ginger would be used for irritability and heat, or fermented soybeans for knotted pain.
[Annotation] In cold damage, if the exterior pathogen is unresolved, and a physician causes severe purging with pill medicines, without leading to chest oppression-hardness (Jie Xiong) or epigastric fullness-stiffness (Pi Ying), it has not yet become an adverse condition. However, persistent body heat indicates the exterior syndrome remains unrelieved. Slight mental restlessness signifies heat sinking into the chest. For exterior heat lingering in the chest, which is mild and slight, neither purging nor clearing is appropriate. Instead, Gardenia and Fermented Soybean Decoction should be used to slightly induce vomiting to vent the heat, thereby resolving the slight mental restlessness. Since the vomiting method contains the intent of dispersal, body heat can also be resolved.
[Collected Notes] Wang Hu said: Mistaken purging with pills fails to eliminate pathogenic heat, hence body heat persists. Pathogenic qi takes advantage of deficiency to lodge in the chest, causing slight mental restlessness.

Formula for Gardenia and Dried Ginger Decoction (Zhizi Ganjiang Tang)
Gardeniae Fructus (broken open, 14 pieces), Zingiberis Rhizoma (Dried Ginger, 2 liang).
The above two herbs are boiled in 3.5 sheng of water to obtain 1.5 sheng. The dregs are removed, and the decoction is divided into two doses. Take one dose warm. If vomiting occurs, stop taking subsequent doses.
[Commentary] The dried ginger in this formula should be Fermented Soybean (Xiangchi). The rationale is detailed in the correction text below the previous scripture passage.

After five or six days of cold damage, following severe purging, if body heat persists and there is a knotted pain in the heart region, the disease is not yet resolving. Gardenia and Fermented Soybean Decoction (Zhizi Chi Tang) is indicated.
[Commentary] The fermented soybean in this formula should be dried ginger. The rationale is also detailed in the correction text below the previous scripture passage.
[Annotation] Five or six days into cold damage is when the pathogen is in the interior. After severe purging, if body heat subsides and the heart and chest feel harmonious, this indicates impending resolution. Now, since body heat persists, the pathogen remains at the exterior. Knotted pain in the heart region results from excessive purging causing interior cold; thus, it is said the disease is not yet resolving. In this pattern of exterior heat and interior cold, warming the interior would hinder resolving the exterior heat, while resolving the exterior would hinder treating the interior cold. Therefore, using the cold nature of gardenia and the hot nature of dried ginger together to induce vomiting allows for both resolving the exterior and warming the interior. Would body heat and knotted pain not then be completely resolved? This illustrates Zhang Zhongjing's clever method for treating difficult dual patterns; other cases can be inferred similarly.
[Collected Notes] Wang Kentang said: The phrase "body heat persists" warrants careful consideration. In chest oppression-hardness, there is no fever, indicating heat is not at the exterior. Here, since body heat persists, only the vomiting method is suitable.
Cheng Yingmao said: Pain described as "knotted" resembles chest oppression-hardness, but chest oppression-hardness lacks significant fever, indicating heat has fully entered the interior as excess pathogen. Here, persistent body heat means the knotting resulted from purging, and the external pathogen still resides at the exterior; thus, it is said the disease is not yet resolving.

Whenever using Gardenia Decoctions, patients with a history of loose stools should not be given them.
[Annotation] After sweating, vomiting, or purging, if symptoms such as vexation, shortness of breath, retching, irritability, fullness, and knotted pain in the heart region occur, they are all suitable for treatment with gardenia-type decoctions to induce vomiting. This is because the pathogen lingers between the chest and stomach, binding with heat, deficiency, fluid retention, qi stagnation, or cold without forming solid accumulation. The pathological trend is upward, consistent with the classic principle: "For pathogens located above, use the method of evacuating upwards." If these symptoms exist without prior sweating, vomiting, or purging, it indicates an excess pathogen, which cannot be treated by the mild action of gardenia decoctions; instead, heavy agents like Melon Twig Powder (Gua Di San) should be used. If a patient has a history of chronic loose stools, even if these symptoms are present, they should not be administered due to long-standing interior deficiency. Administering them might expel the pathogenic factors but would severely impair healthy qi, as the pathological trend is downward, and inducing vomiting would likely cause further complications. Although Materia Medica does not list gardenia as an emetic, Zhang Zhongjing used it as such. Why? Gardenia is not inherently an emetic, but its bitter taste can induce vomiting; thus, it is used to vent heat.
[Commentary] Emetics are not limited to gardenia; various herbs can serve this purpose. One must accurately diagnose whether the pathogen in the chest and stomach is cold or heat, food stagnation or fluid retention, phlegm or qi stagnation, and identify the cause of obstruction preventing the extension of chest-stomach yang qi. Then, using the appropriate herb to induce vomiting will lead to recovery. To vomit cold, use dried ginger and cinnamon bark; to vomit heat, use gardenia and bitter tea; to vomit food stagnation, use Pingwei San with salt; to vomit fluid retention, use Wuling San with fresh ginger; to vomit phlegm and thin saliva, use tangerine peel; to vomit qi stagnation, use immaturity bitter orange and magnolia bark. For patients with weak constitution, the dosage should be small, supplemented with uplifting herbs like those in Buzhong Yiqi Tang. For those with strong constitution, the dosage may be larger, supplemented with potent emetics like melon twig or veratrum for better effect. When preparing emetic decoctions or powders, use sour rice soup, plain water, or thin rice gruel. Prepare over ten cups. Have the patient drink one cup rapidly, then stimulate the throat with a finger to induce vomiting. Drink another cup and repeat until vomiting is smooth and rapid. Mild sweating on the head, forehead, and body will naturally follow. As symptoms alleviate, the treatment is effective; there is no need to consume the remaining medicine. Over-vomiting may damage chest yang qi even if the pathogen is eliminated. Modern physicians have long dismissed vomiting as an obsolete ancient method. This is because Zhang Zhongjing's principles have faded and his methods lost, explaining their reluctance to use them. Not knowing its efficacy and hesitating to use it is forgivable; but dismissing it as unusable is unacceptable. Pathogens located above cannot be cured without vomiting. If lay practitioners discourage patients from taking emetics due to fear, leading to delays and complications, turning mild cases severe and severe cases fatal, who bears the blame? Moreover, when sweating, vomiting, and purging methods are applied correctly, effects are immediate. How can future physicians discuss only sweating and purging while neglecting vomiting, allowing ancient methods to perish!
[Collected Notes] Cheng Zhi said: This states contraindications for gardenia. Patients with chronic loose stools have interior deficiency; administering bitter-cold herbs prevents upward vomiting and causes downward purgation, hence it is prohibited.
Zhang Zhicong said: Mentioning gardenia but not fermented soybean clarifies that gardenia's bitterness causes downward purgation; thus, it is contraindicated for patients with chronic loose stools.

In Taiyang disease, with floating-tight pulse, absence of sweating, fever, and body ache persisting for eight or nine days without resolution, if the exterior syndrome remains, sweating should be induced. After taking medicine, symptoms may slightly subside. The patient may experience mental restlessness and eye closure/dizziness; in severe cases, nasal bleeding (Xu) will occur, after which the disease resolves. This is due to excessive yang qi constraint. Ephedra Decoction (Mahuang Tang) is indicated.
[Commentary] Zhang Jianshan stated: The five characters "Ephedra Decoction is indicated" should not appear after "due to excessive yang qi constraint." How could Ephedra Decoction be used after resolution via nasal bleeding? His view is correct. Furthermore, preceding "after taking medicine," there is no mention of what medicine was taken. These five characters should be moved earlier to fit logically.
[Annotation] In Taiyang disease, with floating-tight pulse, no sweating, fever, and body ache persisting for eight or nine days without resolution, the exterior syndrome of cold damage remains, and Ephedra Decoction (Mahuang Tang) should be used to induce sweating. "Slightly subsiding after taking medicine" means sweating has occurred, pathogenic factors have slightly decreased, but not completely. Sweating should still be attempted. If delayed, yang pathogen remains constrained in the Ying level, unable to vent. Heat merges with Yang causing mental restlessness; heat constrains in Yin causing eye closure/dizziness. "Severe" means extreme heat. Extreme heat in the Ying level forces blood in vessels to flow recklessly, causing nasal bleeding. Nasal bleeding allows heat to exit with blood, resolving the disease. This occurs due to excessive yang constraint.
[Collected Notes] Cheng Zhi said: Floating-tight pulse indicates remaining exterior syndrome. Even after eight or nine days, Ephedra Decoction should be used for sweating. After administration, symptoms slightly subside. Vexation, dizziness, and severe nasal bleeding result from heat constrained in Ying and excessive yang qi interacting with dispersing herbs. However, once nasal bleeding occurs, heat resolves with blood. This emphasizes using Ephedra Decoction primarily for inducing sweating, not for use after resolution via nasal bleeding.
Zhang Lu said: Symptoms slightly subsiding after medication, followed by renewed vexation, indicates residual pathogen remains. Severe dizziness and vexation indicate heat abundant in meridians, forcing blood recklessly to cause nasal bleeding. Residual heat resolves with blood. Because nasal bleeding follows sweating, it is termed "excessive yang qi." Some argue that if heat remains after sweating and nasal bleeding, Ephedra Decoction should disperse remaining pathogen. This is incorrect. If heat were truly incomplete, how would the phrase "resolves after nasal bleeding" apply?

In Taiyang disease, with floating-tight pulse, fever, and absence of sweating, spontaneous nasal bleeding leads to recovery.
[Annotation] Floating-tight pulse, fever, and no sweating in Taiyang disease constitute cold damage signs, requiring sweating. Failure to sweat when indicated is a missed opportunity. Missed sweating causes cold to close the Wei level and heat to constrain in the Ying level. Initially, if resolution does not occur via Wei-level sweating, prolonged constraint will eventually lead to resolution via Ying-level nasal bleeding. Thus, in Taiyang disease, external resolution occurs only through sweating or nasal bleeding. Having missed sweating in the Ying level, blood heat in the Ying flows recklessly, causing spontaneous nasal bleeding. Heat resolves with nasal bleeding, leading to self-recovery.
[Collected Notes] Fang Youzhi said: This continues from the previous clause, discussing milder symptoms to show cases of spontaneous recovery without treatment, warning against erroneous interventions. Taiyang disease with floating-tight pulse, fever, and no sweating matches the previous clause but lacks body ache, indicating milder severity. Thus, treatment is unnecessary; spontaneous nasal bleeding leads to recovery. Sweat is the fluid of blood; northerners call nasal bleeding "red sweat," reflecting this concept.
Cheng Zhi said: Spontaneous nasal bleeding ensures recovery even without sweating. Humans contracting cold develop heat; nasal bleeding allows venting and recovery.
Zhang Lu said: Flowing nasal bleeding disperses pathogenic heat with blood. Blood loss precludes sweating. If spontaneous nasal bleeding does not occur, Ephedra Decoction should induce sweating. Successful sweating resolves pathogen without nasal bleeding; if residual pathogen remains, nasal bleeding will still occur for resolution.

In cold damage, with floating-tight pulse, failure to induce sweating leads to nasal bleeding. Ephedra Decoction (Mahuang Tang) is indicated.
[Annotation] This follows the previous clause to provide treatment guidance. Cold damage with floating-tight pulse requires sweating by law. Failure to sweat is a missed opportunity. Missed sweating causes heat constraint in the Ying level, leading to nasal bleeding. Ephedra Decoction is indicated. If Ephedra Decoction had been used early before nasal bleeding, sweating would resolve the disease, preventing nasal bleeding. Or, if it resolves spontaneously via nasal bleeding as in the previous clause, medication is unnecessary.
[Commentary] In early cold damage, if aversion to cold is not severe, heat involvement is suspected, often leading to nasal bleeding. In heat-dominant/cold-minor cases, heat exits with nasal bleeding, followed by sweating, resolving both exterior and heat. In heat-minor/cold-dominant cases, even if heat exits with nasal bleeding, sweating may not follow, leaving the exterior unresolved. Using Qinglong Decoction or Mahuang Tang before nasal bleeding achieves dual resolution via sweating and bleeding. If nasal bleeding has already occurred and sweating fails, exterior remains unresolved, Ma Huang Tang or Gui Zhi Tang can harmonize Ying and Wei, but should be supplemented with minor amounts of Scutellaria, Coptis, rhinoceros horn, or rehmannia to clear heat and cool blood, protecting yin blood. However, after significant nasal bleeding, Mahuang Tang or Qinglong Decoction should not be used lightly; improper use violates the prohibition against sweating patients with nasal bleeding history.
[Collected Notes] *Ren Shu* states: Post-nasal-bleeding floating pulse indicates suitability for Mahuang Tang; post-nasal-bleeding faint pulse contraindicates Mahuang Tang, favoring Scutellaria and Paeonia Decoction. Floating pulse post-bleeding indicates unresolved exterior; faint pulse indicates resolved exterior. This reveals Zhang Zhongjing's principle for using Mahuang Tang post-bleeding.
Fang Youzhi said: Cold damage with floating-tight pulse implies more cold than wind. The previous two clauses involved more wind than cold: the first caused nasal bleeding due to incomplete sweating after medication; the second resolved spontaneously due to mildness. This clause involves nasal bleeding due to lack of sweating from dominant cold. The distinction lies here. Dominant cold requires sweating; failure to sweat causes heat constraint and blood disorder, leading to nasal bleeding. Nasal bleeding disperses yang wind pathogen. Mahuang Tang disperses the remaining cold.
Cheng Zhi said: This addresses nasal bleeding caused by unconstrained cold pathogen, requiring warm dispersal. Nasal bleeding without sweating results from cold entering Ying failing to vent. Unresolved cold causes persistent bleeding; thus, Mahuang is used again, not waiting for bleeding. This differs from the previous clause regarding heat/cold.
Cheng Yingmao said: Generally, nasal bleeding in cold damage arises from inherent Ying heat. Once constrained by cold, Ying cannot withstand suppression and rises.

In cold damage, constipation for six to seven days with headache and fever indicates excess in the interior, suggesting Ba Xia Xie Xin Tang or Da Cheng Qi Tang (Chengqi Tang). However, if urine is clear, the pathogen is not in the interior but remains at the exterior, requiring sweating. If headache is severe, nasal bleeding will likely occur; Gui Zhi Tang is indicated.
[Commentary] The character "ruo" (if) in "if headache" should be "ku" (severe). Severe headache is the sign for inevitable nasal bleeding. If interpreted as "if," any headache could cause nasal bleeding.
[Annotation] Constipation for six to seven days in cold damage suggests interior excess, potentially requiring purging. Persistent headache and fever indicate unresolved exterior, potentially requiring sweating. Facing this dilemma, urine clarity distinguishes the location. Turbid red urine indicates interior heat; even with exterior signs, treat interior heat with Chengqi Tang. Clear white urine indicates heat remains at the exterior; even with constipation, treat exterior pathogen with Gui Zhi Tang. Regardless of interior/exterior status, severe headache indicates intense heat in Ying, inevitably causing nasal bleeding, which resolves Ying heat. Before nasal bleeding, absence of sweating requires Mahuang Tang; presence of sweating requires Gui Zhi Tang to induce sweating and resolve without bleeding.
[Collected Notes] Wang Hu said: Persistent headache stems from wind-cold obstructing upwards, heat abundant in meridians, inevitably leading to nasal bleeding. Treating before bleeding with Mahuang or Gui Zhi Tang, verified by urine testing, is Zhang Zhongjing's brilliant method.
Wei Litong said: The mention of nasal bleeding in this clause is predictive, not an observed symptom.

If Taiyang disease remains unresolved, heat binds in the Bladder. The patient exhibits manic behavior. If blood passes spontaneously, recovery ensues. If exterior symptoms remain unresolved, internal attack is premature; resolve the exterior first. Once the exterior is resolved, if only lower abdominal urgency and knotted sensation persist, internal attack is permissible. Taohe Chengqi Tang is indicated.
[Annotation] Unresolved Taiyang disease typically transmits to Yangming. If it does not transmit to Yangming but pathogenic heat follows the meridian, stasis forms in the Bladder Ying level, causing manic-like behavior. Manic-like state results from internal binding of stasis-heat disturbing the Heart. At this stage, spontaneous blood passage leads to self-recovery. If blood does not pass spontaneously, or passage is incomplete, heat and stasis accumulate in the lower Bladder, causing lower abdominal urgency and knotted sensation. If exterior symptoms persist, internal attack is contraindicated; resolve exterior first with Mahuang Tang. Once exterior resolves, if only lower abdominal urgency/pain remains, internal attack is permitted using Taohe Chengqi Tang (Tiao Wei Cheng Qi Tang plus Peach Kernel), which clears heat and drives out blood stasis. Since pathogen follows the Taiyang meridian, Cinnamon Twig is added to resolve exterior and unblock Ying. Taking medicine before meals ensures rapid downward action of the drug force.
[Commentary] Unresolved Taiyang disease not transmitting to Yangming, but heat following the meridian into the interior, is called "invading the root." Invading the root refers to invading the Bladder Fu organ. The Wei level of the Bladder Fu corresponds to the Qi level; the Ying level of the Bladder Fu corresponds to the Blood level. Heat invading the Qi level impedes Qi transformation, binding heat with water, constituting invasion of the Wei-level interior, presenting as Wu Ling San syndrome. Heat invading the Blood level impedes blood circulation, binding heat with blood, constituting invasion of the Ying-level interior, presenting as Taohe Chengqi Tang syndrome. Both are root-invading patterns, and both formulas treat root invasion, but one promotes urination (water) and the other purges from below (blood); their treatments differ.
[Collected Notes] Yu Chang said: Taohe Chengqi Tang uses Cinnamon Twig to resolve the exterior, similar to Da Chaihu Tang. This confirms that heat following the Taiyang meridian cannot be resolved without Cinnamon Twig.
Cheng Zhi said: Unresolved Taiyang disease follows the meridian into the Fu, causing heat binding in the Bladder. Manic-like behavior results from internal stasis-heat disturbing the Heart. Spontaneous blood passage allows heat to resolve with stasis. However, exterior symptoms must resolve before directly attacking lower abdominal knotted pathogen. Adding Peach Kernel to Tiao Wei Cheng Qi Tang targets the blood site; adding Cinnamon Twig unblocks blood vessels and resolves Taiyang meridian-following pathogen.
Wang Hu said: The Bladder is an organ in the lower abdomen. Bladder heat binding affects the Wei level (urinary difficulty) or Ying level (blood stasis), creating urgency/knotted sensations, confirming lower jiao blood stasis syndrome. Taohe Chengqi Tang attacks lower jiao blood stasis and treats lower abdominal urgency; it is not merely for clearing Bladder heat binding.

Formula for Peach Kernel and Rheum Decoction (Taohe Chengqi Tang)
Peach Kernel (skin and tip removed, 50 pieces), Cinnamomi Ramulus (3 liang), Rhei Radix et Rhizoma (4 liang), Natrii Sulfas (2 liang), Glycyrrhizae Radix et Rhizoma (roasted, 2 liang).
The above five herbs are boiled in 7 sheng of water to obtain 2.5 sheng. The dregs are removed, Natrii Sulfas is added, and the mixture is heated briefly until boiling, then removed from fire. Take 5 he of the warm decoction before meals, three times daily. Mild purgation is expected.

In Taiyang disease lasting six to seven days, if exterior symptoms persist, but the pulse is faint and deep, and contrary to expectation, chest oppression-hardness does not form, yet the patient becomes manic, it is because heat is in the lower jiao, and the lower abdomen should be hard and full. If urination is normal, blood letting is required for recovery. This is due to Taiyang pathogen following the meridian, causing stasis-heat in the interior. Purging with Didang Tang is indicated.
[Annotation] In Taiyang disease lasting six to seven days with persistent exterior symptoms, the pulse should be floating and large. A faint and deep pulse indicates exterior Taiyang syndrome combined with interior Shaoyin pulse, corresponding to Mahuang Fuzi Xixin Tang syndrome. Alternatively, pathogen entering the interior causes chest oppression-hardness or zang-jie. Here, lacking Taiyang-Shaoyin combined symptoms, and not forming chest oppression-hardness or zang-jie, but exhibiting mania, indicates Taiyang meridian-following stasis-heat binds not in the upper jiao Wei level, but in the lower jiao Ying level, causing lower abdominal hardness/fullness. Normal urination confirms blood stasis in the lower jiao. Recovery requires blood evacuation; if spontaneous passage does not occur, purging is necessary. Only Didang Tang is sufficient to drive out blood stasis; this is the definitive method.
[Collected Notes] Yu Chang said: When blood stasis progresses to mania, heat attacks the Heart. Taohe Chengqi Tang is insufficient to move blood, and Cinnamon Twig insufficient to scatter pathogen. Only a general striking straight in can win the battle, hence named Didang Tang. "Di" means arriving/reaching. It is the most appropriate and unchangeable excellent method.
Zhang Lu said: Pathogen binding in the chest uses Xianxiong Tang to purge fluids; pathogen binding in the lower abdomen uses Didang Tang to drive out blood.
Cheng Zhi said: Faint-deep pulse indicates pathogen binding in the interior. Persistent exterior symptoms without chest oppression-hardness show Taiyang meridian pathogen binds in the lower jiao, not upper. Normal urination indicates blood pathology without qi pathology.
Cheng Yingmao said: Heat binding in the Qi level causes urinary difficulty; heat binding in the Blood level causes blood stasis. Once blood stasis accumulates and stagnates, only powerful purging of blood can achieve recovery.

Formula for Didang Tang